HomeMy Public PortalAbout9855 LA ROSA DR_Sewer__ l
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76A8420 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING p— 1)--3
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JOHN A. LAMBIE. County Engineer ADOR.SS 7
14
WILLIAM A. JENSEN, Supt of Building
LOCALITY ' /y lf+ t1
NEAREST , I
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DESCRIPTION OT NO. Q ,,[[ A WNER/YY L (J
BLOCK TRACT Yk MAIL
ESS //_//1'j///_'f_r/_�f/
NO. OF BLOG3. C tiE
SIZE OF LOT NOW ON LOT ` CITY MbAlq tj VIA TEL. NO. d] E
USE OF A � ln OISTfl ICT NO. GROUP MAP PROCESSED BY
BUILDINGS ENL �sl��l YV6 BK PG
CONTRACTOR � V\
1317 cc�E 7P•.7VE-AVS (/�
ADDRESS MO _ - CONNENE CTION DATA
CITY JEL. NO. STATION / DEPTH
❑ STATE MA NHO LE REFERENCE
REGISTRATION NO. ❑ COUNTY �^ LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CORF) TI� LENGTH FROM Y
/ HOUSE SEWER CONNECTING TO [^ Y. P.L. M.L.TO P.L. _ O
PUBLICSE@ WER 55.00 -7
SEPTIC TANK.SEEPAGE PIT OR P.C.NO. V
PITS ANO/OR ORgINF1ELD f10.00 CO.IMP. NO. JOB NO. /�
/30
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. C ` O
PRIVATE DISPOSAL SYSTEM 33.00 J,
CONNECT ADDITIONALBLDG.OR AFFIDAVIT MV SEME RECORD.INSTR.NO. PATE
WORK TO HOUSE SEWE R $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD y
EXTH..CESSPOOL.ORYWELL.MANHOLE $5.00 +/
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING !�
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s z oo -
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL e£e
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TOACTOR ToTHE PUBLIC SECONNW THE ABOVE DESCRIBE. E%ISTIN6 DWELLING APPROVALS DATE INSPECTOWS SIGNATURE
SIGNED THI hDAY
OF _19 �r
OWNER OR ` NEW HOUSE SEWER / y
OWN ERBAGENT CONNECT ADDITIONAL
ADDRESS /IA '
BUILDING OR WORK
SEPTIC TANK; PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
FIELp
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLV MBING AND SEWERS. CESSPOOL ❑ ORYW ELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOB ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT A THE LEGAL OWNER OF. ANO INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE AB6 ESL'RIBED SIDENTIAL PROP TY.
/� ABANDON HOUSE SEWER
SIGNATURE F ,yr ,V
OF PERMITTEE a BACKFILL SEPTIC TANKS ❑
SEEP.PITISI ❑ CESSPOOL
VALIDATION ROBERT A. WOOD
-
W CASH
J SUPERVISING MECHANICAL ENGINEER
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